Community Feedback Form

Thank you for taking the time to offer feedback regarding your experience with Adventist Health. We appreciate your providing this information so that we can consider it as we strive to become the best place to receive care.
Have you received service at Adventist Health?*

YesNo
If yes, please list the approximate date of service:

MonthDayYear
If yes, please select the location of service:

Adventist Health HanfordAdventist Health ReedleyAdventist Health SelmaAdventist Health TulareAdventist Health Medical OfficePhysicians Network Medical OfficeKerr Outpatient CenterOther
If you received care at a medical office, please specify which city.
Comments
Additional information that is helpful to us: (optional)
1. Have you used the services of another hospital in the last year?

YesNo
If so, would you share the facility name?
2. What health care services would you like to see added at Adventist Health?
3. Do you travel out of town for physician services?

YesNo
If so, what type of service?
Name

FirstLast
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
By providing your details and clicking "Submit" you agree to:
- Receive communications from Adventist Health through email, SMS, text, or calls by an automated telephone dialing system for the purpose of Adventist Health maintaining its relationship with you and providing you information related to services you may be interested in.
- Adventist Health collecting and disclosing to third parties personal information and communications for the purpose of fulfilling your inquiries or requests for services or information.
Should be Empty:

Additional information that is helpful to us: (optional)